AIDS

AIDS

Definition

Acquired immune deficiency syndrome (AIDS) is an infectious disease caused by the human immunodeficiency virus (HIV). There are two variants of the HIV virus, HIV-1 and HIV-2, both of which ultimately cause AIDS.

Description

AIDS was first recognized in the United States 1981 in homosexual men. Today is seen in both homosexual and heterosexual men and women. AIDS is the advanced form of infection with HIV virus. This virus may not cause recognizable symptoms for a long period after the initial exposure (latent period). As of early 2009, no vaccine was available to prevent HIV infection. Until such a vaccine is developed, all forms of HIV/AIDS therapy are focused on improving the quality and length of life for people who are infected by slowing or halting the replication of the virus and treating or preventing infections and cancers that often develop in people with AIDS.AIDS is one of the most devastating worldwide public health problems in recent history. The United States Centers for Disease Control and Prevention (CDC) estimated that in 2006 944,000 people in the United States had been diagnosed with AIDS since the disease was identified in 1981. In 2006, an additional 1-1.2 million Americans were diagnosed as infected with HIV but not yet showing symptoms (HIV positive). However, in early 2009, the CDC issued a statement that they now thought that earlier the HIV-positive estimates were too low, as many more people than were originally estimated are living with unreported or undiagnosed HIV infection.According to the August 2008 report issued by the Joint United Nations Programme on HIV/AIDS (UNAIDS), as of 2007, approximately 33 million people worldwide are HIV positive. Over half of the 33 million are women and this statistic has remained stable for several years. The highest number of cases is found in sub-Saharan Africa and Southeast Asia.More than 70% of HIV infections are transmitted through sexual contact. Traditionally in the United States, the majority of cases were found in homosexual or bisexual men. In 2007, about half of new HIV cases were acquired by men having sex with other men. Fewer than 20% of HIV-positive Americans were women. However, this is not the case worldwide, where transmission by heterosexual individuals is common.

Risk factors

AIDS can be transmitted in several ways. The risk factors for HIV transmission vary according to the method of transmission.

Sexual contact. People at greatest risk are those who do not practice safer sex by always using a condom, those who have multiple sexual partners, those who participate in anal intercourse, and those who have sex with a partner who has HIV infection and/or other sexually transmitted diseases (STDs). In the United States and Europe, most cases of sexually transmitted HIV infection result from homosexual contact, whereas in Africa, the disease is spread primarily through sexual intercourse among heterosexuals. Most people with AIDS in the United States are between 25 and 44 years of age.

Transmission in pregnancy. High-risk mothers include women sexually active with bisexual men, intravenous drug users, and women living in neighborhoods with a high rate of HIV infection among heterosexuals. The chances of transmitting the disease to the child are higher in women in advanced stages of the disease. Breast feeding increases the risk of HIV transmission as HIV passes into breast milk. The rate of pediatric HIV transmission in the United States had decreased substantially because of HIV testing and improved drug treatment for infected mothers, so fewer than 1% of AIDS cases now occur in children under age 15. In the developing world, mother to infant transmission remains epidemic. In 2006, AIDS was the single most common cause of death in children under age 5 in South Africa, while worldwide children account for about 10% of all AIDS cases.

Exposure to contaminated blood. Risk of HIV transmission among intravenous drug users increases with the frequency and duration of intravenous use, frequency of needle sharing, number of people sharing a needle, and the rate of HIV infection in the local population. In 2006, about 19% of men with AIDS and 25% of women with AIDS contracted the disease through sharing needles during intravenous drug injection. With the introduction of new blood product screening in the mid-1980s, HIV transmission through blood transfusions became rare in the developed world. However, contaminated blood is still a significant source of infection in the developing world.

Needle sticks or body fluid splashes among health care professionals. Transmission through theses sources accounts for fewer than 0.3% of all HIV infections in the United States. This rate reflects the emphasis on universal safety precautions (e.g., use of gloves, face shields, proper disposal of needles) among health care professionals and first responders.

HIV is not transmitted by handshakes or other casual non-sexual contact, coughing or sneezing, or by bloodsucking insects such as mosquitoes.

AIDS in women

Women exposed to HIV infection through heterosexual contact are the most rapidly growing risk group in the United States. The percentage of AIDS cases diagnosed in American women has risen from 7% in 1985 to about 25% in 2006. According to the CDC, in 2006 approximately 278,400 women in the United States were living with HIV/AIDS. The rate was highest among black women and lowest among white women. About 75% of these women contracted HIV through high-risk heterosexual activity; almost all of the remainder acquired the infection through needle sharing.The prevalence of women with HIV in the United States is low compared to the rate in many countries in the developing world. Worldwide about half the people living with HIV are women. According to the United Nations, in 2005 about 59% of women living in sub-Saharan Africa are infected with HIV. The vast majority of them were infected through sex with an infected male partner.

AIDS in children

Since AIDS can be transmitted from an infected mother to a fetus during pregnancy or to an infant during the birth process or through breastfeeding, all infants born to HIV-positive mothers are considered a high-risk group. However, prenatal drug treatment of HIV-positive mothers in developed countries has reduced the number of children born infected with HIV. In the developing world, drug treatment is either not available or not affordable. According to the United Nations Children's Fund (UNICEF) worldwide 2.3 million children under age 13 were living with HIV in 2006. The previous year, about 380,000 children died of AIDS and more than half a million children were newly infected. UNICEF estimates that at least 15 million children have lost at least one parent to AIDS.AIDS is the leading causes of death in children under age five many parts of Africa and Southeast Asia. The interval between exposure to HIV and the development of AIDS is shorter in children than in adults. Infants infected with HIV have a high chance of developing AIDS within one year and dying before age three. In the remainder, AIDS progresses more slowly; the average child patient survives to about seven years of age. Some survive into early adolescence.

Causes and symptoms

AIDS is a disease that can damage any of the body's major organ systems because HIV destroys immune system cells. HIV attacks the body through three disease processes: immunodeficiency, autoimmunity, and nervous system dysfunction.Immunodeficiency describes the condition in which the body's immune response is damaged, weakened, or is not functioning properly. In AIDS, immunodeficiency results from the way that the virus binds to a protein called CD4, which is primarily found on the surface of certain subtypes of white blood cells. After the virus has attached to the cell's CD4 receptor, the virus-CD4 complex refolds to uncover another receptor called a chemokine receptor that helps mediate entry of the virus into the cell. One chemokine receptor in particular, CCR5, has been the focus of recent research after studies showed that defects in its structure (caused by genetic mutations) result in a slowing or stopping of the progression of AIDS. Scientists hope that this discovery will lead to the development of drugs that trigger an artificial mutation of the CCR5 gene or target the CCR5 receptor.Once HIV has entered the cell, it can replicate intracellularly and kill the cell in ways that are still not completely understood. In addition to killing some lymphocytes directly, the AIDS virus disrupts the functioning of the remaining immune system cells. Because the immune system cells are destroyed, a wide variety of infections and cancers can take advantage of a person's weakened immune system (opportunistic infections/diseases).The course of AIDS generally progresses through three stages, although not all patients will follow this progression precisely:

Acute retroviral syndrome

Acute retroviral syndrome describes a group of symptoms that can resemble mononucleosis and that may be the first sign of HIV infection in 50-70% of all patients and 45-90% of women. Most patients are not recognized as HIV positive during this phase and may not seek medical attention. The symptoms are similar to those of many other diseases and may include fever, fatigue, muscle aches, loss of appetite, digestive disturbances, weight loss, skin rashes, headache, and chronically swollen lymph nodes (lymphadenopathy). Some patients will experience a form of meningitis during this phase in which the membranes that cover the brain and spinal cord become inflamed. Acute retroviral syndrome develops between one and six weeks after infection and lasts for two to three weeks. Blood tests during this period will indicate the presence of HIV virus (viremia) and the appearance of the viral p24 antigen in the blood.

Latency period

After the virus enters a person's lymph nodes during the acute retroviral syndrome stage, the disease becomes latent for 10 years or more before symptoms of advanced disease develop. During latency, the virus continues to replicate in the lymph nodes, where it may cause one or more of the following conditions:

Persistent generalized lymphadenopathy (PGL)

Persistent generalized lymphadenopathy, or PGL, is a condition in which HIV continues to produce chronic, painless swellings in the lymph nodes during the latent period. The lymph nodes that are most frequently affected by PGL are those in the areas of the neck, jaw, groin, and armpits. PGL affects between 50-70% of patients during latency.

Constitutional symptoms

Many patients develop low-grade fevers, chronic fatigue, and general weakness. HIV also may cause a combination of food malabsorption, loss of appetite, and increased metabolism that contribute to AIDS wasting syndrome.

Other organ systems

At any time during the course of HIV infection, patients may develop a yeast infection in the mouth called thrush, open sores or ulcers, or other infections of the mouth; diarrhea and other gastrointestinal symptoms that cause malnutrition and weight loss; diseases of the lungs and kidneys; and degeneration of the nerve fibers in the arms and legs. HIV infection of the nervous system leads to general loss of strength, loss of reflexes, and feelings of numbness or burning sensations in the feet or lower legs.

Late-stage disease (AIDS)

AIDS is usually marked by a very low number of CD4+ lymphocytes, followed by a rise in the frequency of opportunistic infections and cancers. Doctors monitor the number and proportion of CD4+ lymphocytes in the patient's blood in order to assess the progression of the disease and the effectiveness of different medications. About 10% of infected individuals never progress to this overt stage of the disease.

Opportunistic infections

Once the patient's CD4+ lymphocyte count falls below 200 cells/mm 3, he or she is at risk for a variety of opportunistic infections. The infectious organisms may include the following:

Fungi. The most common fungal disease associated with AIDS is Pneumocystis carinii pneumonia (PCP). PCP is the immediate cause of death in 15-20% of AIDS patients. It is an important measure of a patient's prognosis. Other fungal infections include a yeast infection of the mouth (candidiasis or thrush) and cryptococcal meningitis.

Protozoa. Toxoplasmosis is a common opportunistic infection in AIDS patients that is caused by a protozoan. Other diseases in this category include isoporiasis and cryptosporidiosis.

AIDS dementia complex and neurologic complications

AIDS dementia complex is usually a late complication of the disease. It is unclear whether it is caused by the direct effects of the virus on the brain or by intermediate causes. Loss of reasoning ability, loss of memory, inability to concentrate, apathy and loss of initiative, and unsteadiness or weakness in walking mark AIDS dementia complex. Some patients also develop seizures. There are no specific treatments for AIDS dementia complex.

Musculoskeletal complications

Patients in late-stage AIDS may develop inflammations of the muscles, particularly in the hip area, and may have arthritis-like pains in the joints.

Oral symptoms

In addition to thrush and painful ulcers in the mouth, patients may develop a condition called hairy leukoplakia. The CDC also regards this condition as an indicator of full-blown AIDS. Hairy leukoplakia is a white area of diseased tissue on the tongue that may be flat or slightly raised. It is associated with infection by the Epstein-Barr virus.

AIDS-related cancers

Patients with late-stage AIDS may develop Kaposi's sarcoma (KS), a skin tumor that primarily affects homosexual men. KS is the most common AIDS-related malignancy. It is characterized by reddish-purple blotches or patches (brownish in people with dark skin) on the skin or in the mouth. About 40% of patients with KS develop symptoms in the digestive tract or lungs. KS may be caused by a herpes virus-like sexually transmitted disease agent rather than HIV.The second most common form of cancer in AIDS patients is a tumor of the lymphatic system (lymphoma). AIDS-related lymphomas often affect the central nervous system and develop very aggressively.Invasive cancer of the cervix (related to certain types of human papilloma virus [HPV]) is an important diagnostic marker of AIDS in women.While incidence of AIDS-defining cancers such as Kaposi's sarcoma and cervical cancer have decreased since increase use of antiretroviral therapy, other cancers have increased in AIDS patients. People with HIV have shown an increased incidence of lung cancer, head and neck cancers, Hodgkin's lymphoma, melanoma, and anorectal cancer.

Diagnosis

Because HIV infection produces a wide range of symptoms, the CDC has compiled a list of conditions regarded as defining AIDS. The physician will use the CDC list to decide whether the patient falls into one of these three groups:

definitive diagnoses with or without laboratory evidence of HIV infection

definitive diagnoses with laboratory evidence of HIV infection

presumptive diagnoses with laboratory evidence of HIV infection.

Almost all the symptoms of AIDS can occur with other diseases. The general physical examination may range from normal findings to symptoms that are closely associated with AIDS. These symptoms are hairy leukoplakia of the tongue and Kaposi's sarcoma. During an examination, the doctor will look for an overall pattern of symptoms rather than any one definitive finding.

Laboratory tests for HIV infection

Blood tests (serology)

Diagnostic blood tests for AIDS are given to individuals in high-risk populations, pregnant women, health care and public service workers who have been exposed to HIV, those who have symptoms associated with AIDS, or others who fear they may have been exposed to the virus. The first blood test for AIDS was developed in 1985. Patients who are being tested for HIV infection are usually given an enzyme-linked immunosorbent assay (ELISA) test for the presence of HIV antibody in their blood. Positive ELISA results are then tested with a Western blot or immunofluorescence (IFA) assay for confirmation. The combination of the ELISA and Western blot tests is more than 99.9% accurate in detecting HIV infection within four to eight weeks following exposure. The polymerase chain reaction (PCR) test can be used to detect the presence of viral nucleic acids in the very small number of HIV patients who have false-negative results on the ELISA and Western blot tests. These tests are also used to detect viruses and bacteria other than HIV and AIDS.

Other laboratory tests

In addition to diagnostic blood tests, other blood tests are used to track the course of AIDS in patients that have already been diagnosed. These include blood counts, viral load tests, p24 antigen assays, and measurements of 2-microglobulin (2M).Doctors will use a wide variety of tests to diagnose the presence of opportunistic infections, cancers, or other disease conditions in AIDS patients. Tissue biopsies, samples of cerebrospinal fluid, and sophisticated imaging techniques, such as magnetic resonance imaging (MRI) and computed tomography scans (CT) are used to diagnose AIDS-related cancers, some opportunistic infections, damage to the central nervous system, and wasting of the muscles. Urine and stool samples are used to diagnose infections caused by parasites. AIDS patients are also given blood tests for syphilis and other sexually transmitted diseases.

Diagnosis in children

The CDC recommends HIV testing as a part of standard prenatal care for all pregnant women. When a pregnant woman tests positive for HIV, testing of her infant ideally begins within 48 hours of birth. Testing is repeated at between 1 and 2 months of age and again at age 3-6 months. Testing of infants uses a different technique to detect the presence of HIV virus. Infants can be diagnosed by direct culture of the HIV virus, PCR testing, and p24 antigen testing. By one month of age, results are highly accurate. Diagnostic blood testing in children older than 18 months is similar to adult testing, with ELISA screening confirmed by Western blot.In terms of symptoms, children are less likely than adults to have an early acute syndrome. They are, however, likely to have delayed growth, a history of frequent illness, recurrent ear infections, a low white blood cell count, failure to gain weight, and unexplained fevers. Children with AIDS are more likely to develop bacterial infections, inflammation of the lungs, and AIDS-related brain disorders than are HIV-positive adults.

Treatment

Drug treatment guidelines for HIV/AIDS change frequently as new drugs are approved and new drug regimens developed. Two principles currently guide doctors in developing drug regimens for AIDS patients: using combinations of drugs rather than one medication alone; and basing treatment decisions on the results of the patient's viral load tests. Current information on United States Food and Drug Administration-(FDA)approved drugs by class can be found at the United States Department of Health and Human Services Aids Info Website at <http://www.aidsinfo.nih.gov/DrugsNew/Default.aspx?MenuItem=Drugs>. Individuals interested in participating in a trial of new HIV/AIDS drugs under development can find a list of clinical trials currently accepting volunteers at <http://www.clinicaltrial.gov>. There is not cost to volunteers to participate and some medical care and testing is provided.

Treatment of opportunistic infections and malignancies

Most AIDS patients require complex long-term treatment with medications for infectious diseases. This treatment is often complicated by the development of resistance in the disease organisms. AIDS-related malignancies in the central nervous system are usually treated with radiation therapy. Cancers elsewhere in the body are treated with chemotherapy.

Prophylactic treatment for opportunistic infections

Prophylactic treatment is treatment that is given to prevent disease. AIDS patients with a history of Pneumocystis pneumonia, with CD4+ counts below 200 cells/mm3 or 14% of lymphocytes, weight loss, or thrush should be given prophylactic medications. Drugs that may be given include antibiotics such as trimethoprim-sulfamethoxazole (Bactrim) or pentamidine (Pentam-300, Pentacarinat) and anti-fungals such as amphotericin B (AmBisome), flucytosine (Ancobon), and clotrimazole (Lotrim AF, Mycelex, Femizole-7). All these drugs can have undesirable side effects.

Anti-viral treatments

In recent years researchers have developed drugs that suppress HIV replication, as distinct from treating its effects on the body. These drugs fall into several classes:

Nucleotide reverse transcriptase inhibitors (also called nucleoside analogues). These drugs work by interfering with the action of HIV reverse transcriptase inside infected cells, thus ending the virus's replication process. These drugs include zidovudine (Retrovir), lamivudine (Epivir), and abacavir (Ziagen) and many others. They are often used in used in multi-drug combinations.

Non-nucleoside reverse transcriptase inhibitors. This class of drugs binds to an enzyme that is necessary for the HIV virus to reproduce. Examples of drugs in this class are viramune, delavirdine (Rescriptor), and efavirenz (Sustiva) and others.

Integrase inhibitors. Integrase inhibitors prevent the virus from inserting its own genetic material into the DNA of the infected cell. This stops the virus from replicating. Integrase was the only FDA-approved drug in this class as of early 2009. Several investigational drugs in this category were in clinical trials at that time.

Fusion inhibitors and entry inhibitors. Fusion inhibitors block specific proteins on the surface of the virus or the CD4+ cell. These proteins help the virus gain entry into the cell. The only FDA-approved fusion inhibitor as of early 2009 was enfuvirtide (Fuzeon). Entry inhibitors block HIV from entering cells. The only FDA-approved fusion inhibitor as of early 2009 was maraviroc (Selzentry). Several drugs in this class are, as of 2009, in pre-approval clinical trials.

Stimulation of blood cell production

Because many patients with AIDS have abnormally low levels of both red and white blood cells, they may be given medications to stimulate blood cell production. Epoetin alfa (erythropoietin) may be given to anemic patients. Patients with low white blood cell counts may be given filgrastim or sargramostim.

Alternative treatment

Alternative treatments for AIDS can be grouped into two categories: those intended to help the immune system and those aimed at pain control. Treatments that may enhance the function of the immune system include Chinese herbal medicine and western herbal medicine, macrobiotic and other special diets, guided imagery and creative visualization, homeopathy, and vitamin therapy. Pain control therapies include hydrotherapy, reiki, acupuncture, meditation, chiropractic treatments, and therapeutic massage. Alternative therapies also can be used to help with side effects of the medications used in the treatment of AIDS.

Prognosis

As of early 2009, there was no cure for AIDS and no vaccine to prevent infection. Treatment stresses aggressive combination drug therapy for those patients with access to the expensive medications and who tolerate them adequately. The use of these multi-drug therapies has significantly improved and prolonged the life of HIV/AIDS patients in the United States.Researchers are actively working on producing preventative and therapeutic vaccines for HIV. Preventative vaccines immunize an individual against a disease, so that he or she does not become infected. A therapeutic vaccine, also called a treatment vaccine, does not keep someone from getting a disease the way a preventative vaccine does. Instead, therapeutic vaccines are used to boost the body's immune system in order to help control infection. The potential exists to prolong life indefinitely using these and other drug therapies to boost the immune system, keep the virus from replicating, and ward off opportunistic infections and malignancies.

Prevention

As there is no cure for AIDS, prevention of HIV infection becomes extremely important in controlling the disease. Efforts to prevent the spread of AIDS include:

Restricting sexual activity to a single partner and practicing safer sex (i.e., always using a condom). Besides avoiding the risk of HIV infection, condoms are successful in reducing other sexually transmitted diseases and unwanted pregnancies. Before engaging in a sexual relationship with someone, getting tested for HIV infection is recommended.

Avoiding needle sharing among intravenous drug users.

Donating one's own blood before planned major surgery to prevent risk of infection from a blood transfusion, although blood supplies are extremely safe in the developed world.

Practicing universal safety precautions when handling body fluids or needles. Healthcare professionals, first responders, and teachers, for example, are now trained in these precautions.

Testing for HIV infection by anyone how suspects infection. If treated aggressively and early, the development of AIDS may be postponed. If HIV infection is confirmed, it is also vital to let past sexual partners know so that they can be tested and receive medical attention.

Key Terms

Acute retroviral syndrome

A group of symptoms resembling mononucleosis that often are the first sign of HIV infection.

AIDS dementia complex

A type of brain dysfunction caused by HIV infection that causes difficulty thinking, confusion, and loss of muscular coordination.

Antibody

A protein produced by the immune system in response to a foreign protein or toxin called an antigen. Each different antigen stimulates the production of a different antibody.

Antigen

Any substance that stimulates the body to produce antibody.

Autoimmunity

A condition in which the body's immune system produces antibodies in response to its own tissues or blood components instead of foreign particles or microorganisms.

CCR5

A chemokine receptor; defects in its structure caused by genetic mutation cause the progression of AIDS to be prevented or slowed.

CD4

A type of protein molecule in human blood, sometimes called the T4 antigen, that is present on the surface of 65% of immune cells. The HIV virus infects cells with CD4 surface proteins, and as a result, depletes the number of immune system cells (T cells, B cells, natural killer cells, monocytes) in the individual's blood. Most of the damage to an AIDS patient's immune system is done by the virus' destruction of CD4+ lymphocytes.

Chemokine receptor

A receptor on the surface of some types of immune cells that helps to mediate entry of HIV into the cell.

Hairy leukoplakia of the tongue

A white area of diseased tissue on the tongue that may be flat or slightly raised. It is caused by the Epstein-Barr virus and is an important diagnostic sign of AIDS.

Hemophilia

Any of several hereditary blood coagulation disorders occurring almost exclusively in males. Because blood does not clot properly, even minor injuries can cause significant blood loss that may require a blood transfusion, with its associated minor risk of infection.

Human immunodeficiency virus (HIV)

A transmissible retrovirus that causes AIDS in humans. Two forms of HIV are now recognized: HIV-1, which causes most cases of AIDS in Europe, North and South America, and most parts of Africa; and HIV-2, which is chiefly found in West African patients. HIV-2, discovered in 1986, appears to be less virulent than HIV-1 and may also have a longer latency period.

Immunodeficient

A condition in which the body's immune response is damaged, weakened, or is not functioning properly.

Kaposi's sarcoma

A cancer of the connective tissue that produces painless purplish red (in people with light skin) or brown (in people with dark skin) blotches on the skin. It is a major diagnostic marker of AIDS.

Latent period

Also called incubation period, the time between infection with a disease-causing agent and the development of disease.

Lymphocyte

A type of white blood cell that is important in the formation of antibodies and that can be used to monitor the health of AIDS patients.

Lymphoma

A cancerous tumor in the lymphatic system that is associated with a poor prognosis in AIDS patients.

Macrophage

A large white blood cell, found primarily in the bloodstream and connective tissue, that helps the body fight off infections by ingesting the disease-causing organism. HIV can infect and kill macrophages.

Monocyte

A large white blood cell that is formed in the bone marrow and spleen. About 4% of the white blood cells in normal adults are monocytes.

(MAC) infection

A type of opportunistic infection that occurs in about 40% of AIDS patients and is regarded as an AIDS-defining disease.

Non-nucleoside reverse transcriptase inhibitors

The newest class of antiretroviral drugs that work by inhibiting the reverse transcriptase enzyme necessary for HIV replication.

Nucleoside analogues

The first group of effective anti-retroviral medications. They work by interfering with the AIDS virus' synthesis of DNA.

Opportunistic infection

An infection by organisms that usually do not cause infection in people whose immune systems are working normally.

Persistent generalized lymphadenopathy (PGL)

A condition in which HIV continues to produce chronic painless swellings in the lymph nodes during the latency period.

pneumonia (PCP)

An opportunistic infection caused by a fungus that is a major cause of death in patients with late-stage AIDS.

Progressive multifocal leukoencephalopathy (PML)

A disease caused by a virus that destroys white matter in localized areas of the brain. It is regarded as an AIDS-defining illness.

Protease inhibitors

The second major category of drug used to treat AIDS that works by suppressing the replication of the HIV virus.

Protozoan

A single-celled, usually microscopic organism that is eukaryotic and, therefore, different from bacteria (prokaryotic).

Retrovirus

A virus that contains a unique enzyme called reverse transcriptase that allows it to replicate within new host cells.

T cells

Lymphocytes that originate in the thymus gland. T cells regulate the immune system's response to infections, including HIV. CD4 lymphocytes are a subset of T lymphocytes.

Thrush

A yeast infection of the mouth characterized by white patches on the inside of the mouth and cheeks.

Viremia

The measurable presence of virus in the bloodstream that is a characteristic of acute retroviral syndrome.

Wasting syndrome

A progressive loss of weight and muscle tissue caused by the AIDS virus.

Each year about 5 million people contract AIDS worldwide, and 3 million die of it. Some 40-50 million are estimated to be living with the disease. The gender incidence is approximately equal. The highest prevalence is in some African countries, where as many as 25% of the adult population may test HIV positive; about 70% of the world's infected population lives in sub-Saharan Africa. The first cases of AIDS were reported in the U.S. in June 1981. During the succeeding 2 decades an estimated 1.4 million people in this country were infected with HIV and 816,149 cases of AIDS and 467,910 deaths were reported to the U.S. Centers for Disease Control and Prevention (CDC). The numbers of new AIDS cases and deaths declined substantially after introduction of combination antiretroviral therapy in the late 1990s. The annual number of new cases of AIDS in the U.S. has remained stable at about 40,000, with 16,000 deaths since 1998. The number of people infected with HIV continues to increase, and of an estimated 1 million, one fourth are unaware that they are infected. In the U.S., AIDS is the leading cause of death among men 25-44 years old, and the fourth leading cause of death among women in the same age group. The development of effective antiretroviral agents (for example, reverse transcriptase inhibitors and protease inhibitors) and of quantitative plasma HIV RNA assays that can monitor progression of disease and response to treatment has shifted the goal of management in AIDS from prophylaxis and treatment of opportunistic infections to achievement of remission through suppressive therapy. Immune compromise is monitored by serial CD4 counts, viral replication by plasma HIV RNA assay (that is, plasma viral load, PVL). Indications for starting antiretroviral therapy are the appearance of symptoms of opportunistic infection, decline of the CD4 count below 350/mm3, or viral load exceeding 30,000 copies/mL. The CD4 count is considered a more sensitive predictor of disease progression than viral load. Empiric treatment may be begun early (within 6 months after conversion to HIV-positive status) in an effort to preserve immune function and mobilize the patient's own defenses against the virus. But current guidelines advise deferring treatment as long as possible so as to limit induction of drug resistance. Protease inhibitors have been shown to be highly effective antiretroviral agents and standard treatment regimens combining 2 reverse transcriptase inhibitors with 1 protease inhibitor ("triple therapy") have clearly demonstrated superiority over monotherapy. These drugs are expensive. Regimens are often complex, with varying requirements for fasting and timing of doses, and adverse effects and drug interactions are common. Protease inhibitors have been associated with elevation of cholesterol and triglycerides, insulin resistance, and disfiguring lipodystrophy. In one large study, more than one half of HIV-infected adults under treatment were found to be infected with strains of virus resistant to one or more antiretroviral drugs, and strains of HIV that are resistant to all available protease inhibitors have appeared. The rationale for current AIDS regimens is an effort to eradicate HIV infection by inhibiting spread of virus to new cells until all infected cells have died. However, actual cure seldom if ever occurs. A small number of resting CD4 memory cells in treated patients with undetectable plasma HIV RNA levels harbor HIV proviral DNA capable of replication, and these cells may survive for months or years. Macrophages and CNS neurons may serve as an anatomic sanctuary for HIV into which antretroviral drugs cannot penetrate in adequate concentration. When antiretroviral therapy is initiated early, CD4 helper cell counts rise, CD4 cell activity is preserved, and HIV RNA levels may remain undetectable for long periods. But in about 50% of patients with advanced disease, even multidrug regimens fail to suppress plasma viral RNA to undetectable levels. Many treatment failures result from poor compliance with multidrug regimens. Failure of one therapeutic regimen often precludes success with others because of the high degree of cross-resistance among antiretroviral drugs. After failure of an initial regimen, genotypic testing can be used to identify mutations in the HIV genome that confer resistance to one or more classes of HIV drugs. Many patients remain vulnerable to opportunistic infections despite restoration of CD4 counts to normal, probably because some subpopulations of T cells have been annihilated and cannot be recovered even after HIV has been suppressed. Moreover, even HIV-infected patients with undetectable viral loads must still be considered infectious. In a small set of those infected with HIV, impairment of immunity progresses to AIDS slowly or not at all. CD8 T-cells from such nonprogressors have been found to produce proteins called α-defensins. Evolving standards of treatment in HIV disease include aggressive prophylaxis in pregnancy and after accidental needle stick and sexual assault. Administration of antiretroviral agents to HIV-positive mothers before birth and during labor and delivery, and to newborns for the first 6 weeks of life, markedly decrease the risk of vertical transmission of HIV infection. The risk of HIV infection after occupational parenteral exposure to blood from an HIV-infected patient is approximately 0.3%. Postexposure prophylaxis with antiretroviral agents continued for 28 days have been shown to reduce the risk by 80%. The selection of agents depends on the source patient's therapeutic history. Efforts to develop a vaccine against HIV have been hampered by the unique properties of the virus and the long incubation period of AIDS. Early in the 21st century, public health authorities sought to make HIV testing a routine part of medical care, to facilitate diagnosis outside formal clinical settings, to prevent new infections by educating people and their sexual partners, and to decrease perinatal HIV transmission through routine HIV testing of pregnant women and of infants whose mothers were not screened.

AIDS

AIDS

(ādz)

n.

A severe immunological disorder caused by the retrovirus HIV, resulting in a defect in cell-mediated immune response that is manifested by increased susceptibility to opportunistic infections and to certain rare cancers, especially Kaposi's sarcoma. It is transmitted primarily by exposure to infected body fluids, especially blood and semen.

AIDS

AIDS

Acquired Immunodeficiency Syndrome. An immunosuppressing condition which is intimately linked to infection by a retrovirus, human immunodeficiency virus (HIV-1). Bangui definition A points-based system used to define AIDS in countries where HIV testing is not available. It was developed by workers from the CDC and WHO at a conference held in Bangui, Central African Republic, in 1985, and gives the most points for severe weight loss, protracted asthenia, recalcitrant fever and diarrhoea. AIDS is diagnosed with scores of 12 or more.Clinical findings Weight loss exceeding 10% of body weight, protracted asthenia, continuous fever for >1 month, diarrhoea >1 month, persistent cough, oropharyngeal candidiasis, relapsing cutaneous herpes, generalised pruritic dermatosis, generalised lymphadenopathy, Kaposi's sarcoma.Management Long-term survival after HIV infection is possible, but requires aggressive multi-agent therapy; once clinical AIDS develops, it is fatal, despite temporary response to various therapies.AIDS is also an abbreviation for:Academy of International Dental StudiesAccident/Incident Data SystemAccretive Industrial Development Syndrome. A non-medical term used in real estate.All Individuals Deserve Support. A slogan used by an AIDS support group.

AIDS

AIDS

acronym for Acquired Immune Deficiency Syndrome, a serious disease caused by Human Immunodeficiency Virus (HIV) which debilitates the immune system. HIV 1 attaches to the CD4 receptor present on T LYMPHOCYTES and MACROPHAGES. The viral RNA enters the host cell and is transcribed by REVERSE TRANSCRIPTASE into DNA. This viral DNA becomes integrated into the chromosomal DNA of the host. There it may control the production of new HIV particles, which are budded off from the infected host cell. Alternatively, the integrated DNA may remain latent and not be detected by the immune system. HIV avoids the host's IMMUNE RESPONSE by remaining in vacuoles within macrophages. HIV also shows high rates of ANTIGENIC VARIATION, since errors during replication of HIV RNA to DNA cause numerous changes in the nature of the ENVELOPE PROTEINS of the virus. Not everyone who carries HIV develops AIDS, but all infected individuals can pass it on. There are three major routes of transmission:

through sexual intercourse,

by transfer of blood on needles shared by drug users or by transfusion of contaminated blood (only before 1985 in the USA), or accidentally by contaminated needles, or

by mother to baby before or during birth or by means of the milk. Drug users and homosexuals are high-risk groups, but in central Africa it is now widespread amongst heterosexuals where a second virus, HIV 2 is also present. This is endemic throughout West Africa but does not appear to have resulted in an epidemic of the disease.

From the time of infection by HIV, AIDS normally develops within ten years, though there are now drugs which may be used to extend this time. The immune failure, which is characteristic of AIDS, occurs as a consequence of a gradual decline in the number of CD4 T lymphocytes. Eventually the infected person succumbs to a variety of infections by BACTERIA, FUNGI, protozoa or viruses and/or develops a cancer(s) such as Kaposi's Sarcoma.

In order for a person to be infected, HIV must be present in the transmitted body fluids, and its concentration (very high in blood) determines whether infection takes place. HIV must get into the blood stream and can only enter via an open cut or sore or by contact through the mucous membranes of the anus, rectum, genitalia, mouth or eyes. Outside the body HIV can live up to 15 days in a stable temperature and humidity, if it is in high concentration, but usually only for a short time (a few hours). It is not transmitted by insect bites, through saliva, tears, sweat, faeces or urine. There are documented cases of oral infection and male to female transmission is much more frequent than female to male. There are records of Simian immunodeficiency virus being transmitted to humans, but these have so far not given rise to the disease. The virus in chimpanzees can be transmitted but not similiar viruses from other animals.

There are difficulties in developing an effective VACCINE against HIV, because the virus is so adept at avoiding the host immune defence system. Research is in progress, using both conventional and very unconventional approaches, to develop such a vaccine. Various chemotherapeutic agents are being tested. AZT (azidothymidine), which inhibits virus replication, has been used, but it has side effects and only helps certain patients. Radiation has also been employed but again there are side effects. So far around 22 million people have died of AIDS and a further 40 million are living infected by HIV.

constrictive band syndrome intrauterine development of deep, tight, circumferential folds around leg/foot, and compromised limb development distal to band (e.g. autoamputation; marked oedema of distal tissues); thought to relate to strands of amniotic membrane enwrapping the developing limb

'second-class travel' syndrome pulmonary thromboembolism due to prolonged periods of inactivity, e.g. passengers (who have been static for > 4 hours during long-haul intercontinental air flights) develop deep-vein thrombosis; the clot detaches, passing through venous circulation and heart, to block the pulmonary artery; characterized by sudden collapse and death; passengers on long-haul flights are advised to undertake leg muscle exercises regularly throughout the duration of the flight, wear 'antithrombotic' elasticated hosiery and consider medication with aspirin in the weeks before long-haul flight

sinus tarsi syndrome sensation of unsteadiness when walking on gravel/uneven ground and ongoing pain in lateral tarsal area just distal to and level with lateral malleolus, subsequent to inversion sprain/excess rearfoot pronation (e.g. as in rearfoot rheumatoid arthritis); local symptoms are exacerbated by heel inversion/eversion; treated by non-steroidal anti-inflammatory drugs, local immobilization, orthoses or steroid injection

talar compression syndrome posterior ankle pain when foot is maximally plantarflexed at ankle joint; due to compression of posterior tubercle of talus on posterior margin of distal end of tibia; note: similar condition occurs with os trigonum, which impinges on posteroinferior margin of tibia (seeTable 9)

Note: BFJHS is diagnosed in the presence of two major criteria, or one major and two minor criteria, or four minor criteria (adapted from Grahame R, Bird HA, Child A, Dolan AL, Fowler-Edwards A, Ferrell W, Gurley-Green S, Keer R, Mansi E, Murray K, Smith E. The British Society Special Interest Group on Heritable Disorders of Connective Tissue Criteria for the Benign Joint Hypermobility Syndrome. "The Revised (Brighton 1998) Criteria for the Diagnosis of the BJHS". Journal of Rheumatology 2000; 27:1777-1779).

Table 2: Features of complex regional pain syndrome

Phase

Features

Acute phase (duration: 2-3 months)Reversible

Severe burning pain, warmth, swelling and joint stiffness within a limb: not confined to a dermatome or myotomeBone demineralizationSymptoms (exacerbated by limb dependence, contact or stress) persist for 2-3 months

Note: BFJHS is diagnosed in the presence of two major criteria, or one major and two minor criteria, or four minor criteria (adapted from Grahame R, Bird HA, Child A, Dolan AL, Fowler-Edwards A, Ferrell W, Gurley-Green S, Keer R, Mansi E, Murray K, Smith E. The British Society Special Interest Group on Heritable Disorders of Connective Tissue Criteria for the Benign Joint Hypermobility Syndrome. "The Revised (Brighton 1998) Criteria for the Diagnosis of the BJHS". Journal of Rheumatology 2000; 27:1777-1779).

Lie on a bench on the unaffected side, with the unaffected hip and knee slightly flexed, in order to maintain balance; flex the affected hip and straighten the affected knee so that the affected leg hangs off the bench; allow the iliotibial band of the affected leg to be stretched by gravitational pullLie on a bench on the affected side with the affected leg in line with the body and the hip and knee locked; flex the unaffected (upper) leg; place the hands on the bench immediately under the shoulder and push the trunk upwards as far as possible to apply stretch to the lateral area of the affected leg

Stand erect, with the affected leg behind the normal leg so that the knee of the affected leg rests on the posterior aspect of the non-affected knee; rotate the trunk (on transverse plane) away from the affected leg and attempt to touch the heel of the affected leg

Lie on a bench on the unaffected side, with the unaffected hip and knee slightly flexed, in order to maintain balance; flex the affected hip and straighten the affected knee so that the affected leg hangs off the bench; allow the iliotibial band of the affected leg to be stretched by gravitational pullLie on a bench on the affected side with the affected leg in line with the body and the hip and knee locked; flex the unaffected (upper) leg; place the hands on the bench immediately under the shoulder and push the trunk upwards as far as possible to apply stretch to the lateral area of the affected leg

Stand erect, with the affected leg behind the normal leg so that the knee of the affected leg rests on the posterior aspect of the non-affected knee; rotate the trunk (on transverse plane) away from the affected leg and attempt to touch the heel of the affected leg

AIDS,

AIDS

acquired immune deficiency syndrome of humans, caused by the lentivirus, human immunodeficiency virus 1 (HIV1), less commonly HIV2. The virus initially infects macrophages and then attacks and destroys T helper CD4 lymphocytes, thereby producing immunodeficiency and resulting in death, usually after a very prolonged incubation period followed by a very prolonged clinical course. A very similar virus SIV1 causes simian AIDS in captive macaque monkeys. A further similar virus SIV2 has been isolated from healthy green monkeys.

Patient discussion about AIDS

Q. Why AID spred? and How?

A. if you mean AIDS- it spread mostly because people don't practice safe sex or sharing needles when injecting drugs. here is a nice tutorial about HIV, it is also specify the ways of infection-http://www.nlm.nih.gov/medlineplus/tutorials/aids/htm/lesson.htm

Q. The HIV test came back POSITIVE! My very close friend 'Demonte'. One day in December as he was returning from a business trip, his wife met him at the airport with terrible news. During a routine pregnancy check up, her doctor had administered an HIV test along with other blood-work. The HIV test came back POSITIVE! The doctor wanted to begin administering drugs immediately but the cost of these drugs here when compared to their family income was prohibitive. I helped him with some of my savings. He already sold his favorite sentimental car to save his precious wife. Now i want to know is there any NATURAL medicine to cure this? Hope it costs less and available.

A. there are no effective natural remedy for HIV. the medications are very hard ones that try to control the virus from spreading (cannot eliminate it though). no herbal remedy or nutrition change will do that.

AGOURA HILLS - This is the last week for donations to the 21st annual ``Santa Comes to Agoura,'' a food drive to help needy families, AIDS victims and abused women in Agoura Hills, Westlake Village and Oak Park.

in some situations, handpicked personnel may need to be assigned to special units for AIDS patients, since some nurses might refuse to treat them on a regular basis (the respondents in this study were not required to work with AIDS victims on a regular basis).

Africa's healthcare workers risk their lives every day to treat legions of AIDS victims, and Congress is to be applauded for its wisdom in requiring devices that protect workers as well as patients," he added.

Among other problems, the protease inhibitors don't work for about 30 percent of recipients, require complex regimens involving up to 40 pills a day, and cost as much as $16,000 a year, putting them beyond the means of many AIDS victims.

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